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Gastrointest Endosc. 2019 May 11. pii: S0016-5107(19)31688-8. doi: 10.1016/j.gie.2019.04.250. [Epub ahead of print]

Endoscopists systematically undersample patients with long-segment Barrett's esophagus: an analysis of biopsy practices from a quality improvement registry.

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University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado. Electronic address:
GI Quality Improvement Consortium, Bethesda, Maryland.
Feinberg School of Medicine, Northwestern University, Chicago, IL.
University of California, Los Angeles, Los Angeles, CA.
University of North Carolina at Chapel Hill, Chapel Hill, NC.



Guidelines recommend systematic biopsies in Barrett's esophagus (BE) to reduce sampling error. Adherence to this biopsy protocol has been suggested as a quality indicator; however, estimates of adherence are not available. Using a national registry, we assessed adherence and identified predictors of adherence to biopsy protocols.


We analyzed data from the GI Quality Improvement Consortium Registry. Data included procedure indication, demographics, endoscopy and pathology results. Patients with an indication of BE screening/surveillance, or an endoscopic finding of BE, were included. Adherence to the Seattle protocol was assessed by dividing BE length by number of pathology jars, with a ratio of ≤2.0 with rounding down (lenient definition) or rounding up (stringent definition) for odd BE lengths considered adherent. Variables associated with adherence were assessed using generalized estimating equations to control for clustering within individual physicians.


Of 786,712 EGDs assessed, 58,709 (7.5%) EGDs in 53,541 patients met inclusion criteria (mean age 61.3 years, 60.4% male, 90.2% white, mean BE length 2.3 cm). When the lenient and stringent definitions for adherence were used, 87.8% and 82.7% EGDs were adherent, respectively. Increasing BE length was the most significant predictor of nonadherence (OR, 0.69; 95% CI, 0.67-0.71). Other predictors included increasing age, male gender, increasing ASA class, and practice location. Performance of EGD by non-GI physicians was associated with nonadherence (OR, 0.07; 95% CI, 0.06-0.10).


Nearly 20% of endoscopies performed in BE patients were not adherent to Seattle protocol. As BE length increases, endoscopists become less compliant with odds of nonadherence increasing by 31% with every 1 cm increase in length.


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